On April 16, 2015, CMS published a proposed rule that would revise the definition of Medicaid mechanized claims processing and information retrieval systems to include Medicaid eligibility and enrollment (E&E) systems, which would make enhanced federal financial participation (FFP) available for such systems on an ongoing basis (current regulatory authority for such enhanced funding
Centers for Medicare & Medicaid Services Developments
HHS Publishes Proposed Stage 3 EHR Incentive Program, Health IT Certification Rules
On March 30, 2015, the Centers for Medicare & Medicaid Services (CMS) published its proposed rule on Stage 3 meaningful use criteria, which focus on the advanced use of Electronic Health Record (EHR) technology to promote improved outcomes for patients. The proposed rule would establish the requirements that eligible professionals (EPs), eligible hospitals, and critical …
CMS Publishes Update to DME Items Subject to Face-to-Face Encounter, Written Order Prior to Delivery Requirements
Today CMS published a notice updating the Healthcare Common Procedure Coding System (HCPCS) codes on the Durable Medical Equipment (DME) List of “Specified Covered Items” that require a face-to-face encounter and a written order prior to delivery (although CMS still is delaying enforcement of the face-to-face examination – but not the detailed written order –…
CMS Publishes Corrections to 2015 Medicare Physician Fee Schedule Final Rule
CMS has published corrections to its final 2015 Medicare physician fee schedule rule. Among other things, the rule reflects a previously-announced correction to the conversion factor for the first quarter of 2015 ($35.7547), revises the April 1 – December 31, 2015 conversion factor to $28.1872 (assuming that Congress does not take action to avert…
CMS Proposed Rules in the Pipeline
CMS recently sent several major proposed rules to the White House Office of Management and Budget for regulatory clearance – the last step before publication in the Federal Register. OMB is reviewing proposed rules to update the skilled nursing facility, inpatient rehabilitation facility, and inpatient psychiatric facility prospective payment systems (PPS) for fiscal year (FY)…
CMS Finalizes SMART Act MSP Appeals Provisions
The Centers for Medicare & Medicaid Services (CMS) has published a final rule that implements Medicare Secondary Payer (MSP) appeals provisions under the Strengthening Medicare and Repaying Taxpayers Act of 2012 (SMART Act). Specifically, the rule addresses the right of appeal and a new multilevel appeal process for liability insurance (including self-insurance), no-fault insurance, and…
CMS Finalizes 2016 ACA Marketplace Plan Benefit & Payment Parameters
The Centers for Medicare & Medicaid Services (CMS) has finalized its Affordable Care Act (ACA) Marketplace health plan payment parameters and essential benefit standards for 2016. The rule addresses numerous policies, including: allocation of risk corridors collections for 2016; recalibration of risk adjustment factors; revisions to reinsurance and cost sharing parameters; user fees for…
Final Medicare Advantage/Part D Rule for Contract Year (CY) 2016
CMS has published a final rule revising Medicare Advantage (MA) and Part D prescription drug benefit regulations for CY 2016. Among other things, the final rule:
- Implements a statutory provision requiring MA and Part D contracts to provide the right to “timely”’ inspection and audit and allowing CMS to require MA organizations or Part
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CMS Issues Final 2016 Funding Methodology for ACA Basic Health Program
On February 24, 2015, CMS published its final methodology and data sources for determining federal payment amounts for states that elect to use the Basic Health Program to offer health benefits to low-income individuals otherwise eligible to purchase coverage through an Affordable Insurance Exchange/Marketplace for 2016. CMS is using the same methodology in 2016 as…
CMS Corrects 2015 Medicare OPPS/ASC Final Rule, Impacts Rates
Today CMS published a notice correcting its November 10, 2014 final rule updating the Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System rates and policies for calendar year 2015. In addition to fixing various technical errors (e.g., status indicator and addenda corrections for specific codes), the notice increases…
CMS Needs More Time to Finalize ACA Rule on Return of Medicare Overpayments
CMS warns requirement to report/return overpayments is in effect even without regulations
The Centers for Medicare & Medicaid Services (CMS) needs more time to finalize its February 16, 2012 proposed rule on reporting and returning of Medicare overpayments, according to a CMS notice to be published on February 17, 2015. The 2012 rule would…
CMS Plans Spring Rulemaking to Modify Meaningful Use Requirements
CMS has announced that it plans to issue regulations this spring to address provider concerns about the burden associated with compliance with Medicare and Medicaid Electronic Health Record (EHR) Incentive Program meaningful use requirements. Specifically, in a January 29, 2015 blog post by Patrick Conway, MD, Deputy Administrator for Innovation and Quality and CMS…
CMS Announces New 6-Month Extension of Moratoria on Enrollment of HHAs, Ambulance Suppliers in Designated Areas
CMS is extending — for another 6 months — its current enrollment moratoria for new ground ambulance suppliers and home health agencies (HHAs) in designated metropolitan areas. The moratoria, which affect enrollment in Medicare, Medicaid, and the Children’s Health Insurance Program, apply to new ground ambulances in the Houston and Philadelphia metropolitan areas and new HHAs…
CMS Publishes Medicare QIO Criteria
CMS has published notices setting forth the criteria it will use to evaluate the effectiveness and efficiency of Quality Innovation Network (QIN) and Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) that entered into contracts with CMS in 2014.
CMS Proposes Changes to Medicare Shared Savings Program/ACO Payment Regulations
On December 8, 2014, CMS published a proposed rule that would revise the regulations governing the Medicare Shared Savings Program, which is intended to encourage physicians, hospitals, and certain other types of providers and suppliers to form Accountable Care Organizations (ACOs) to provide cost-effective, coordinated care to Medicare beneficiaries. The Shared Savings Program now includes more than 330 ACOs in 47 states and serves more than 4.9 million Medicare fee for service (FFS) beneficiaries.Continue Reading CMS Proposes Changes to Medicare Shared Savings Program/ACO Payment Regulations
CMS Proposes Updating Certain Medicare/Medicaid Policies to Recognize Same-Sex Marriages
On December 12, 2014, CMS published a proposed rule to revise selected conditions of participation (CoPs) for providers, conditions for coverage (CfCs) for suppliers, and requirements for long-term care (LTC) facilities to conform with the Supreme Court decision in United States v. Windsor, and ensure that same-sex spouses in legally-valid marriages are recognized and…
CMS Proposes 2016 ACA Marketplace Plan Benefit & Payment Parameters
CMS has issued a proposed rule that would establish ACA Marketplace health plan payment parameters and essential benefit standards for 2016. Specifically, the wide-ranging proposed rule addresses, among other things: the risk adjustment, reinsurance, and risk corridors programs; cost sharing parameters; user fees for federally-facilitated exchanges; standards for qualified health plans, including network adequacy…
CMS Finalizes Rule to Strengthen Medicare Provider Enrollment Regulations and Permit Revocations for Patterns/Practices of Improper Claims Submissions; Defers Expanded Awards for Medicare Fraud Tipsters
On December 5, 2014, the Centers for Medicare & Medicaid Services (CMS) published a final rule that expands the circumstances under which it may deny or revoke the Medicare enrollment of entities and individuals on program integrity grounds, effective February 3, 2015. Among other things, the final rule: allows CMS to deny enrollment to providers, suppliers, and owners that previously were affiliated with an entity with unpaid Medicare debt; allows CMS to deny or revoke enrollment if a managing employee has been convicted of certain felony offenses; and enables CMS to revoke Medicare billing privileges for a “pattern or practice” of improper claims submissions. CMS is not finalizing its proposal to dramatically increase the potential reward for individuals who provide tips leading to the recovery of Medicare funds.
Continue Reading CMS Finalizes Rule to Strengthen Medicare Provider Enrollment Regulations and Permit Revocations for Patterns/Practices of Improper Claims Submissions; Defers Expanded Awards for Medicare Fraud Tipsters
CMS Delaying Enforcement of Medicare Part D Drug Prescriber Enrollment Requirements
CMS has announced that it is delaying a provision of its 2015 Medicare Advantage/Medicare Part D final rule, published on May 23, 2014, that requires physicians and other eligible professionals who prescribe Part D drugs to be enrolled in Medicare (or have a valid opt-out affidavit on file) for their prescriptions to be covered…
CMS Announces 2015 Provider Enrollment Application Fee Amount
Today CMS published a notice announcing that the CY 2015 provider enrollment application fee is $553, up from $542 in 2014. This application fee is required for institutional providers that are initially enrolling or revalidating enrollment in the Medicare or Medicaid program or the Children’s Health Insurance Program (CHIP) or adding a new Medicare…